Citation Nr: 0001006
Decision Date: 01/12/00 Archive Date: 01/27/00
DOCKET NO. 97-21 626 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Winston-
Salem, North Carolina
THE ISSUES
1. Entitlement to a compensable disability evaluation for
patellofemoral pain syndrome of the right knee.
2. Entitlement to a compensable disability evaluation for
patellofemoral pain syndrome of the left knee.
REPRESENTATION
Appellant represented by: The American Legion
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
Theresa M. Catino, Counsel
INTRODUCTION
The veteran served on active military duty from November 30,
1978 to June 30, 1994. Additionally, he had active duty
service for 10 years, 5 months, and 6 days prior to
November 30, 1978.
Previously, in October 1998, the Board of Veterans' Appeals
(Board) remanded this case to the Winston-Salem, North
Carolina, regional office (RO) for further evidentiary
development of the veteran's rating claims with regard to his
service-connected knee disabilities.
FINDINGS OF FACT
1. Right patellofemoral syndrome is manifested by
subpatellar crepitation upon flexion and extension of the
veteran's right knee and tenderness to palpation over the
right lateral semilunar cartilage.
2. Left patellofemoral syndrome is manifested by subpatellar
crepitation upon flexion and extension of the veteran's left
knee.
CONCLUSIONS OF LAW
1. A compensable disability rating for patellofemoral pain
syndrome of the right knee is not warranted. 38 U.S.C.A.
§§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.71
(Plate II), 4.71a (Codes 5257, 5260, and 5261) (1999).
2. A compensable disability rating for patellofemoral pain
syndrome of the left knee is not warranted. 38 U.S.C.A.
§§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.71
(Plate II), 4.71a (Codes 5257, 5260, and 5261) (1999).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Disability evaluations are determined by the application of a
schedule of ratings which is based, as far as can practicably
be determined, on the average impairment of earning capacity.
38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Each
service-connected disability is rated on the basis of
specific criteria identified by diagnostic codes. 38 C.F.R.
§ 4.27 (1999).
The service medical records in the present case indicate
that, at a routine annual physical examination conducted in
January 1976, the veteran reported having experienced swollen
or painful joints, but he did not specify that this
symptomatology was associated with either of his knees. This
evaluation demonstrated that the veteran's lower extremities
(in terms of strength and range of motion) were normal.
In October 1978, the veteran was treated for a laceration of
his left knee incurred while peeling potatoes. A clean cut
knife wound of the left knee was diagnosed. The veteran's
wound was cleaned and sutured, and he was instructed to
report to the local dispensary for removal of the sutures
after six days. A medical report dated two days later
indicated that the veteran had sustained a sports injury to
his left knee.
After the left knee sutures were removed, the veteran began
to experience swelling. Due to post-traumatic ganglion of
the left upper patellar area noted in November 1978, the
veteran was referred to the orthopedic clinic, where, in the
following month, an examination demonstrated a two-centimeter
by two-centimeter soft tissue mass and a well-healed scar.
X-rays were negative. The impression of a mass of the left
knee was given. No fluid was found in the mass. The
examiner instructed the veteran to return in one month for a
"re-check" and noted that exploration would be considered
if the mass was still present.
In September 1980, the veteran complained of a history of
knee pain for the previous six months. He denied any known
injury. Physical examination demonstrated stability and
popping under the patella. The veteran was referred to the
knee clinic where, on the same day, he again described right
knee pain. The evaluation of the veteran's knee showed
crepitus but was otherwise within normal limits. The veteran
was instructed to run at his own pace for one month and to
return to the clinic if effusion occurred. As a result of
this crepitus, the veteran was temporarily placed on
restricted duty.
Thereafter, in January 1982, the veteran reported that he had
a "knee problem." Additionally, he explained that he had a
past history of crepitus and was under treatment. At a
September 1982 examination, the veteran's lower extremities
(in terms of strength and range of motion) were found to be
normal.
In October 1987, the veteran sought treatment for complaints
of popping of, and occasional soreness in, his right knee
when he ran. The veteran reported having had a similar
episode in 1981, when he found relief with anti-inflammatory
medication and physical therapy. Physical examination of the
veteran's right knee in October 1987 demonstrated full range
of motion with popping on flexion and extension, tenderness
of the inferior patella with pressure, no joint line
tenderness, and no pain. X-rays showed no fracture or
foreign body. The veteran was instructed to use ice, and
prescribed medications; he was referred to the physical
therapy clinic for rehabilitation.
Approximately two weeks later, in November 1987, the veteran
underwent an examination of his right knee at the physical
therapy clinic, which examination demonstrated an active
range of motion of this joint which was within normal limits,
patellar crepitus on flexion and extension, no effusion, and
no tenderness with palpation. Ligaments were intact.
In January 1989, the veteran complained of a popping of both
of his knees, especially when running, and chronic right knee
pain. Examination of the veteran's right knee demonstrated
full range of motion, no effusion, and a negative McMurray's
test. Due to the veteran's complaints of chronic right knee
pain with popping, x-rays were taken of this joint in January
1989. The results of this radiographic study were within
normal limits and showed no significant abnormality.
Additionally, the veteran was referred to the physical
therapy clinic where, two weeks later in February 1989, an
examination of both knees demonstrated full range of motion,
crepitus, no swelling, mild tenderness, and a non-antalgic
gait. The veteran's profile included instructions not to run
or jump.
Later in February 1989, the veteran received follow-up
treatment for bilateral knee pain. Examination at that time
showed full range of motion, a normal manual muscle test, no
tenderness or swelling, and a non-antalgic gait.
At a periodic examination conducted in November 1989, the
veteran reported that his right knee "pop[s] . . . out" and
is aggravated by running. This examination, however,
demonstrated that the veteran's lower extremities (in terms
of strength and range of motion) were normal.
In April 1990, the veteran complained of bilateral knee pain.
He was referred to the orthopedic clinic where, in the
following month, an examination demonstrated full range of
motion, no effusion, no instability, and negative x-rays.
The examiner assessed likely mild early degenerative joint
disease, and instructed him to return for follow-up treatment
as the occasion required.
In December 1990, the veteran complained of severe right knee
pain. Examination of the veteran's right knee demonstrated
no swelling, tenderness below the joint, and a range of
motion which was within normal limits. Degenerative joint
disease was assessed. On the following day, the veteran
sought treatment for complaints of right knee pain for two
days and for the onset of a "pop" while playing basketball.
Additionally, the veteran described mild delayed swelling but
denied any giving out or locking. Physical examination
demonstrated full active range of motion, an audible and
palpable click in mid-flexion, no effusion, intact and stable
ligaments, a negative McMurray's test, and tenderness.
Radiographic studies showed a mild infra patellar spur. The
examiner recommended ruling out a right medial meniscus tear.
The veteran was then referred to the physical therapy clinic
where he underwent strengthening rehabilitation of his right
knee between December 1990 and January 1991. A service
medical record from the physical therapy clinic indicates
that, in January 1991, the veteran's right knee pain was
found to be resolving. Examination of the veteran's right
knee at that time demonstrated full active range of motion,
no tenderness, a negative McMurray's test, and no effusion.
The examiner noted that the veteran's right knee remained
stable.
Due to complaints of bilateral knee pain, x-rays were taken
of both of these joints in April 1991. According to the
radiographic report, the x-rays of the veteran's knees were
within normal limits.
At an April 1992 examination, the veteran complained of
painful and arthritic knees. The examiner noted that the
veteran had a P2 profile for arthritis of his knees.
However, the April 1992 examination demonstrated no findings
of a disability of either knee. This evaluation showed that
the veteran's lower extremities (in terms of strength and
range of motion) were normal.
Subsequently, in March 1993, the veteran requested a refill
of his blood pressure medication. Examination of his right
knee at that time showed no effusion, a range of motion which
was within normal limits, intact ligaments, and crepitance on
range of motion testing. Assessments included, in pertinent
part, degenerative joint disease of the right knee. Due to
the veteran's complaints of chronic right knee pain, he was
referred to the orthopedic clinic where, four days after the
initial evaluation, he was afforded another physical
examination. Evaluation of the veteran's right knee at the
orthopedic clinic demonstrated moderate effusion, tenderness,
and crepitus with patellar motion. X-rays showed no evidence
of advanced degenerative joint disease. The impression of
patellofemoral syndrome was given. The veteran was then
referred to the physical therapy clinic where, in April 1993,
he complained of increased pain in the previous three months
secondary to overuse playing basketball. Examination at the
physical therapy clinic showed full range of motion of the
knee, no atrophy, and marked patellofemoral joint crepitus.
The assessment of patellofemoral joint pain was made.
At the retirement examination conducted in January 1994, the
veteran reported that he experienced swelling of his knees
anytime he ran or played sports. While the retirement
examination indicated that the veteran had dry nodule warty
lesions above his right knee and that he had a P-2 profile of
"degenerate arthritis" of both knees, this evaluation also
specifically demonstrated that his lower extremities (in
terms of strength and range of motion) were normal.
The veteran retired from active military duty in June 1994.
Thereafter, in January 1995, he was afforded a VA general
medical examination, at which time he complained of bilateral
knee pain and popping. He also reported that his left knee
swelled a little at times. Physical examination of the
veteran's knees demonstrated the ability to squat to the
floor and to stand back up, normal ranges of motion, and no
abnormalities. X-rays taken of the veteran's knees showed a
spur formation at the superior patella tendinous insertion on
the left and at the inferior patella tendinous insertion on
the right. Otherwise, the veteran's knees were unremarkable.
The examiner concluded that, while the physical examination
of the veteran's knees did not reveal arthritis, the
radiographic studies of these joints did support a diagnosis
of degenerative joint disease.
By a rating action dated in April 1995, the RO granted
service connection for patellofemoral syndrome of the right
knee and for patellofemoral syndrome of the left knee.
Additionally, the RO assigned noncompensable ratings to each
of these service-connected disabilities, effective from July
1994. The veteran's service-connected bilateral knee
disabilities remain evaluated as noncompensably disabling.
According to statement of the case furnished to the veteran
in May 1997 as well as the supplemental statement of the case
mailed to him in May 1999, the RO considered several
applicable diagnostic codes when evaluating his
service-connected bilateral knee disabilities. Specifically,
the RO evaluated the veteran's compensable rating claims in
light of the diagnostic codes which evaluate impairment
resulting from recurrent subluxation or lateral instability
and which rate disability caused by limitation of motion of
the leg.
Diagnostic Code 5257 addresses impairment of the knee
involving recurrent subluxation or lateral instability.
According to this code, evidence of slight recurrent
subluxation or lateral instability warrants the assignment of
a 10 percent disability evaluation. Evidence of moderate
recurrent subluxation or lateral instability will result in
the assignment of a 20 percent disability rating. Evidence
of severe recurrent subluxation or lateral instability
warrants the assignment of a 30 percent disability
evaluation. 38 C.F.R. § 4.71a, Code 5257 (1999).
Additionally, according to the specific diagnostic codes
regarding limitation of motion of the knee, evidence that
flexion of the leg is limited to 60 degrees will result in
the assignment of a noncompensable evaluation. Evidence that
flexion of the leg is limited to 45 degrees warrants the
assignment of a 10 percent disability rating. 38 C.F.R.
§ 4.71a, Code 5260 (1999). Furthermore, evidence that
extension of the leg is limited to 5 degrees warrants the
assignment of a noncompensable rating. Evidence that
extension of the leg is limited to 10 degrees will result in
the assignment 10 percent disability evaluation. 38 C.F.R.
§ 4.71a, Code 5261 (1999).
Throughout the current appeal, the veteran has essentially
asserted that his service-connected bilateral knee
disabilities have increased in severity beyond the impairment
contemplated by the currently assigned noncompensable
ratings. In the claim which was received at the RO in
November 1996, the veteran asserted that he experiences
painful and swollen knees which affect his ability to perform
his duties as a corrections officer.
At the personal hearing conducted at the RO before the
undersigned member of the Board in June 1998, the veteran
testified that he experienced swelling, pain, cracking,
popping, and locking of his right knee when he participates
in any increased activity such as walking, running, or mowing
the lawn. Hearing transcript (T.) at 3-5, 16-17. According
to the veteran's testimony, he wears a brace over his right
knee (which was initially issued by the military) when
performing any type of activity, such as moving the lawn, to
stabilize his right kneecap and to alleviate swelling in the
joint. T. at 9-10. The veteran also testified that he has
not recently sought treatment for his knees and that he
self-medicates his knee condition with Naproxen or Motrin and
with the application of ice, heat, or sports cream.
T. at 6-7, 11. Additionally, the veteran stated that he had
not lately missed work due to his knee condition. T. at 11.
Furthermore, the veteran testified that his left knee is
"better" than his right knee and that his left knee had not
acted up (in terms of pain and swelling, for example) in at
least a year or so. T. at 15-16.
According to the pertinent post-service medical records which
have been obtained and associated with the claims folder, the
veteran complained of right knee pain in August 1996.
Examination of his extremities demonstrated no edema or
lesions. Three months later, the veteran sought treatment
for complaints of severe right knee pain and swelling. He
explained that the pain worsened after he ran and that he
runs two to three miles a day. Physical examination
demonstrated tenderness over the lateral joint and no
effusion or crepitus. X-rays taken of the veteran's right
knee showed osteophytes. A diagnostic impression of knee
pain was given, and the veteran was referred to the
orthopedic clinic.
At a March 1997 evaluation at the orthopedic clinic, the
veteran complained of pain, occasional swelling, and
degenerative joint disease of his right knee which worsened
with his daily jogging. Physical examination of the
veteran's right knee demonstrated "ok" ligaments, no
effusion, tenderness along the anterior medial joint line,
and possible slight medial laxity of the joint anteriorly.
The examiner noted that x-rays taken of the veteran's right
knee in June 1995 and in November 1996 were essentially
within normal limits except for minimal degenerative joint
disease. The impression of a anterior lateral right knee
tear was given.
Thereafter, in February 1998, the veteran was afforded a VA
joints examination, at which time he complained of swelling
of both of his knees after any strenuous activity (including
running, jumping, extended walking, or prolonged standing),
"popping" in both knees from time to time, and having
problems climbing steps. Physical examination of the
veteran's knees demonstrated a normal appearance, no redness
or swelling, slight (but not marked) tenderness along the
joint spaces bilaterally, full range of motion, and crepitus
through the entire range of motion on both sides. The
veteran informed the examiner that he had lost no time from
work for this problem. X-rays taken of the veteran's knees
showed early degenerative changes without significant change
since the last evaluation in January 1995. The examiner
diagnosed residuals of patellofemoral syndrome, including
minimal degenerative joint disease.
In March 1999, the veteran was afforded another VA
examination, at which time he complained of pain, popping,
and swelling in his right knee. He asserted that his knee
occasionally gave out on him. The veteran also stated that
he was not able to withstand any strenuous exercises which
caused impact to his right knee, that he took oral medication
for his knee pain, and that he wore a knee brace
intermittently. At the time of the examination, the veteran
had no complaints referable to his left knee. Additionally,
the veteran denied having lost any time from work in the
previous 12 months.
Physical examination demonstrated the ability to ambulate
without a limp, normal external appearance of both knees, no
measurable atrophy of either thigh or calf, deep tendon
reflexes which were hypoactive but equal bilaterally in the
lower extremities, normal extensor hallucis longus power, and
a sensory and vascular evaluation which was within normal
limits. Evaluation of the veteran's right knee in particular
showed no palpable joint effusion, full range of motion,
subpatellar crepitation upon flexion and extension of the
joint, intact cruciate and collateral ligaments, tenderness
to palpation over the right lateral semilunar cartilage, and
a negative McMurray's sign. Examination of the veteran's
left knee revealed no palpable joint effusion, full range of
motion, subpatellar crepitation upon flexion and extension of
the joint, intact cruciate and collateral ligaments, and no
tenderness to palpation over the medial or lateral joint
space.
X-rays taken of the veteran's knees were negative. The
examiner specifically stated that these radiographic films
did not show evidence of early osteoarthritic changes in
either of the veteran's knees. The examiner diagnosed
patellofemoral arthritis of the right and left knees with
normal x-rays. Furthermore, the examiner stated that he was
unable to provide additional comment on the veteran's
disability (except at the time of the examination).
Right Knee
With regard to the veteran's right knee claim, the Board
acknowledges his assertions that he experiences swelling,
pain, cracking, popping, locking, and instability of his
right knee when he participates in activity such as walking,
running, or mowing the lawn. Hearing transcript (T.) at 3-5,
9-10, 16-17. Additionally, the Board notes that, at the
March 1997 evaluation, the examiner stated that x-rays taken
of the veteran's right knee in June 1995 and in November 1996
were essentially within normal limits.
Furthermore, x-rays taken of the veteran's knees at the
February 1998 VA joints examination showed early degenerative
changes without significant change since the evaluation in
January 1995, and the examiner diagnosed residuals of
patellofemoral syndrome, including minimal degenerative joint
disease. Although the examiner who conducted the March 1999
VA joints examination diagnosed patellofemoral arthritis of
the right knee, the x-rays taken of this knee at that
evaluation were negative. In fact, the examiner specifically
stated that the radiographic films did not show evidence of
osteoarthritic changes in the veteran's knee.
Although the presence of degenerative changes in the
veteran's right knee has not been clearly shown by
radiographic evidence, even if the Board were to evaluate the
veteran's service-connected right knee disability as if
arthritis were present, a compensable rating may not be
assigned. Recent medical examinations have demonstrated that
the veteran has full range of motion of his right knee. Such
a range of motion of the veteran's right knee does not
warrant a compensable rating based upon impairment resulting
from traumatic arthritis (which requires consideration of the
limitation of flexion and extension of the joint). See
38 C.F.R. § 4.71a, Codes 5003, 5010, 5260, and 5261 (1999).
Additionally, even if the presence of arthritis was clearly
shown, a 10 percent rating would not be warranted under Code
5003 unless there is at least some limitation of motion,
albeit noncompensable under Code 5260 or 5261. Diagnostic
Code 5003.
Although regulations recognize that a part which becomes
painful on use must be regarded as seriously disabled, see
38 C.F.R. § 4.40, this provision is qualified by specific
rating criteria applicable to the case at hand. The
provisions of Diagnostic Codes 5260 and 5261 contemplate
limitation of motion of the knee (specifically limitation of
flexion and extension of this joint). Application of the
precepts enunciated in DeLuca v. Brown, 8 Vet.App. 202 (1995)
requires that problems such as pain on use be specifically
considered by any examiner charged with evaluating the
veteran's disability. In this case, the recent examiner has
indicated that it is not possible to say how disabling the
veteran's problem is beyond the specific findings made on
examination. Consequently, to assign an increased rating
based on greater limitation of flexion or extension than
shown on examination merely because the veteran has reported
problems such as pain on use, etc. would render the
examiner's findings and conclusions unnecessary. It does not
appear that this is the result contemplated by the process
mandated by DeLuca, or contemplated by regulation.
Moreover, in the present case, there is no suggestion of
disabling problems that have resulted from disuse. For
example, the recent medical examinations have specifically
demonstrated that, despite the findings of subpatellar
crepitation upon flexion and extension of the right knee
joint and tenderness to palpation over the right lateral
semilunar cartilage, the veteran's service-connected right
knee disability is currently manifested by a normal external
appearance, the ability to ambulate without a limp, no
measurable atrophy of the thigh or calf, deep tendon reflexes
which are hypoactive but equal in the lower extremity, normal
extensor hallucis longus power, a sensory and vascular
evaluation which is within normal limits, no palpable joint
effusion, full range of motion, intact cruciate and
collateral ligaments, a negative McMurray's sign, and no
redness or swelling.
In view of the lack of evidence showing a recent need for
treatment of the veteran's service-connected right knee
disability, the Board gives significant weight to the recent
medical conclusions as to the extent of disability caused by
the veteran's symptoms. The Board concludes, therefore, that
a compensable rating for the veteran's service-connected
right knee disability based upon any functional impairment he
may experience in this joint due to pain on use, etc. cannot
be awarded. See 38 C.F.R. § 4.40 and DeLuca v. Brown, 8
Vet.App. 202 (1995).
Additionally, the most current medical examinations have not
demonstrated laxity or instability of the veteran's right
knee. In fact, the most recent examination of the veteran's
right knee, which was completed in March 1999, demonstrated
intact cruciate and collateral ligaments as well as a
negative McMurray's sign. Without competent evidence of at
least slight recurrent subluxation or slight lateral
instability, a compensable rating of 10 percent for the
veteran's service-connected right knee disability cannot be
awarded. See 38 C.F.R. § 4.71a, Code 5257 (1999).
Consequently, a compensable rating for the service-connected
patellofemoral pain syndrome of the veteran's right knee is
not warranted.
Left Knee
With regard to the veteran's left knee disability, the Board
notes that the veteran has reported little to no current
problem with his left knee. For instance, he testified at
the June 1998 personal hearing that his left knee is
"better" than his right knee and that his left knee has not
acted up (in terms of pain and swelling, for example) in at
least a year or so. T. at 15-16. Furthermore, at the time
of the March 1999 VA joints examination, the veteran denied
having any complaints referable to his left knee.
The Board also acknowledges that X-rays taken of the
veteran's knees at the February 1998 VA joints examination
showed early degenerative changes without significant change
since the evaluation in January 1995 and that the examiner
diagnosed residuals of patellofemoral syndrome, including
minimal degenerative joint disease on x-rays. Furthermore,
the examiner who conducted the March 1999 VA joints
examination diagnosed patellofemoral arthritis of the left
knee. Significantly, however, x-rays taken of the veteran's
knees at the March 1999 examination were negative. In fact,
the examiner (who diagnosed patellofemoral arthritis of the
veteran's left knee) also specifically stated that the
radiographic films did not show evidence of osteoarthritic
changes in the veteran's knee. Furthermore, in diagnosing
left knee arthritis, the examiner also then added "with
normal x-rays."
As with the right knee, even if the Board were to evaluate
the veteran's service-connected left knee disability as if
arthritis were present, a compensable rating could not be
assigned. Recent medical examinations have demonstrated that
the veteran has full range of motion of his left knee. See
38 C.F.R. § 4.71a, Codes 5003, 5010, 5260, and 5261 (1999).
Moreover, there is no indication that the veteran's
complaints of pain, etc. can be quantified beyond the
findings specifically made on examination. DeLuca, supra.
The recent medical examinations have specifically
demonstrated that, despite a finding of subpatellar
crepitation upon flexion and extension of the left knee
joint, the veteran's service-connected left knee disability
is currently manifested by a normal external appearance, the
ability to ambulate without a limp, no measurable atrophy of
the thigh or calf, deep tendon reflexes which are hypoactive
but equal in the lower extremity, normal extensor hallucis
longus power, a sensory and vascular evaluation which is
within normal limits, no redness or swelling, no tenderness
to palpation over the medial or lateral joint space, full
range of motion, no palpable joint effusion, and intact
cruciate and collateral ligaments.
As with the right knee, the absence of any indication of
problems due to disuse and the absence of any suggestion that
the veteran needs ongoing regular care leads the Board to
conclude that functional debility experienced by the veteran,
if any, does not rise to a compensable degree. Id.
Additionally, recent medical examinations have not
demonstrated any laxity or instability of the veteran's left
knee. Without competent evidence of at least slight
recurrent subluxation or slight lateral instability, a
compensable rating of 10 percent for the veteran's
service-connected left knee disability cannot be awarded.
See 38 C.F.R. § 4.71a, Code 5257 (1999). Consequently, a
compensable rating for the service-connected patellofemoral
pain syndrome of the veteran's left knee is not warranted.
As noted above, it has not been clearly established by x-ray
findings that the veteran has arthritis in either knee.
Consequently, the provision of Diagnostic Code 5003 that
allows for the award of a 10 percent rating when there is x-
ray evidence of involvement of two or more major joints does
not aid the veteran in his claim for increased ratings.
ORDER
A compensable disability rating for patellofemoral pain
syndrome of the right knee is denied.
A compensable disability rating for patellofemoral pain
syndrome of the left knee is denied.
MARK F. HALSEY
Member, Board of Veterans' Appeals